Public Health 200- Emergency Preparedness

What constitutes an emergency?
-An unforseen combination of circumstances or the resulting state that calls for IMMEDIATE action
-an URGENT need for assistance and relief

Characteristics of Emergencies
-“Acute” (single episode) and urgent
-Often unanticipated (ex: 9/11), poorly anticipated (ex: latest ebola outbreak or big quake in CA), very recently anticipated (Ex: hurricane sandy.)
-Often have a large number of victims all at once (but most emergencies less important than other, chronic PH problems like obesity, injury, pollution)
-Their nature requires rapid response, hence preparedness
*implies resources one hopes will never be used, and requires quite a lot of planning among many agencies (very difficult to deal with)

Origins of Emergencies (Nature, Industry, Transportation, Terrorism)
-Nature: hurricanes, earthquakes, floods, fires, epidemics, heat emergencies, “bugs” (disease outbreaks), etc.
-Industry: Plant explosions, mine tunnel fires and explosions
-Transportation: multi-car highway collisions, tanker chemical spills, etc.
-Terrorism: Bombings, bioterrorism, shut down electrical grid, poison water supply, cyber terrorism, etc.

Human role in “natural” disasters, 1
-Human habitation patterns:
-Katrina: New Orleans built below sea level, eroded shoreline (this led to Katrina)
-Villages/cities in LMICs near coasts (tsunamis)
-Building codes/practices
-fire damage

Human role in “natural” disasters, 2
*Human technologies:
-Dependence on fossil fuels (mine disasters, oil spills)
-Levees
-Highway systems and evacuation
-Air transportation and spread of epidemics

Origins of Emergency preparedness (EP) in United States
-Congressional Act of 1803: Helped on NH town with assistance after a massive fire
->100 ad hoc pieces of legislation throughout the 19th century, all responding to individual disasters: separate bills = not efficient
-Recurring theme of legislative response to idiosyncratic situations

1930s: flood of legislation
-Reconstruction Corporation (1932): loans for repair and reconstruction of damage to certain public facilities caused by earthquakes (later, other disasters)
-Bureau of Public Roads (1934): Repair damaged highways and bridges
-Flood Control Act (1936): Flood mitigation along Mississippi and other major rivers

Origins of EP (cont’d)
-1940s: Civil Defense programs = air raid warnings and shelters (cold war time)
-Disaster Relief Act (1950): President could declare disaster relief for states and local governments
-Federal Civil Defense Act (1950): nationwide system of CD agencies; air raid drills

Origins of EP (cont’d) 2
-1960s and 70s: Multiple hurricanes and earthquakes- Federal Disaster Assistance Administration in HUD
-1979: Multiple agencies merged into FEMA (Federal Emergency Management Agency, of Katrina fame)
-2003: FEMA and 22 other agencies merged into Dept. of Homeland Security

*important- Authorization for fed. disaster response
(in basic English, the Stafford Disaster Relief and Emergency Act of 1988 allows the president to declare an emergency to provide assistance to anyone if he feels the damage is of sufficient severity and magnitude)
Stafford Disaster Relief and Emergency Assistance Act of 1988 defines qualifying disaster as:
“Any natural catastrophe…or, regardless of cause, any fire, flood, or explosion, in any part of the U.S., which, in the determination of the President, causes damage of sufficient severity and magnitude to warrant major disaster assistance…to supplement the efforts and available resources of States, local governments, and the disaster relief organizations in alleviating the damage, loss, hardship, or suffering caused thereby”

Origins of contemporary PH interest in EP in U.S.
first: 9/11 (2001)- 2800 deaths; 13-15,000 escaped
second: Katrina (2005)- >1800 deaths; 80 billion dollars in damage

Implications for PH of 9/11- inspired interest in EP
-$$$ poured into PH for preparedness: state and local health departments and SPHs vied for grants
-New and substantial interest in PH
*any downside for PH?- concern re redirection of PH from its most important functions (chronic diseases and health behaviors)

FEMA (Federal Emergency Management Agency)
-Coordinates National Response Plan
-Request of support from local to state to federal
-Only President can declare emergencies/disasters under Stafford Act: public assistance, individual assistance

Role of core functions of PH in emergency preparedness
What are those core functions again?
1. Assessment of health of population
2. Development of policy
3. Assurance of availability of necessary services and resources (with emergency planning, local health depts cannot do all by self. requires lots of cooperation/coercion of other parties)

Emergency Management
“Emergency Management is the managerial function charged with creating the framework within which communities reduce vulnerability to hazards and cope with disasters” (primary prevention, tertiary prevention)

Principles of emergency management, 1
1. Comprehensive:
-all hazards, all phases, all stakeholders, all impacts
2. Progressive:
-Managers anticipate possibilities, take preventive and preparatory measures, to build disaster-resistant and disaster-resilient communities (ex: army corps rebuilt levees with hope to prevent next time)
3. Risk driven: Managers use sound risk-management principles in setting priorities and assigning resources

Principles of emergency management, 2
4. Integrated: Managers assure unity of effort among all levels of government and other community organizations (toughest part of all)
5. Collaborative: Managers build team atmosphere, develop consensus, create effective communication
6. Coordinated: managers synchronize activities of stakeholders
7. Flexible: managers uses creative and innovative approaches in solving disaster challenges (ready to adapt, adjust)
8. Professional: managers utilize science and knowledge based approach, ethical practice, public stewardship, and continuous improvement

4 Phases of Emergency Management (M,P,R,R)
1. Mitigation
2. Preparedness
3.Response
4. Recovery

Mitigation
-Prevent hazards from developing into disasters
-Or reduce effects of disasters once they occur
-approaches: -structural or technological. Examples?: levees, emergency shelters, snow removal trucks, EP kits
-non-structural. examples?: evacuation orders and plans, insurance, land-use planning, legislation regarding evacuation

Preparedness *This is a continuous cycle!
A continuous cycle of planning, organizing, training, equipping, exercising, evaluation and improvement activities to ensure effective coordination and the enhancement of capabilities to prevent, protect against, respond to, recover from, and mitigate the effects of natural disasters, acts of terrorism, and other man-made disasters.

Preparedness measures
-Communications plans
-Emergency warning methods (ex; sirens) plus emergency shelters and evacuation plans
-maintenance and training of emergency services, including emergency response teams
-Stockpile, inventory, maintain disaster supplies and equipment
-Emergency readiness kits for individuals
-Organization of trained volunteers
-Casualty prediction

Response (Think re Hurricane Sandy): must be ready to give and do all these things fast
-Mobilization of emergency services and first responders
-Evacuation, search & rescue, quarantine, decontamination, as needed
-Health care, including psychological care
-Supplies (potable water, food, clothing, temporary housing)
-Energy
-Law and order

Recovery: everything torn apart, needs reconciliation
-Rebuild destroyed property, including businesses, housing, infrastructure
-Economic reconstruction
-Community organization reconstruction
-Long-term care for disabilities, including psychiatric

Needs for proper emergency response
-Incident command system
-Planning and practice (rehearsals)
-Coordination
-Communication
-Education of personnel and public
-System redundancies (need backup systems: ex- generator systems at hospitals)
-Supplies (includes strategic stockpiles of med. supplies, vaccines, antibiotics) and beds
-Legal authorities (ex: quarantine)

Incident Command System (ICS)
-Lead: generally top local official (police or fire)
(in MI, State Police Director also directs Emergency Mgt. and Homeland Security)
-State and fed agencies provide back-up resources and technical assistance to LHDS
-Good ICS includes: fire, police, EMS, LHD (with connections to health care orgs.), often transportation or highway authorities.

Readiness of health care institutions
-Disaster plans, coordinated with Local Health Dept.
*itself a problem (coordination plus authority)
-Problem that cannot have enough beds to accommodate need in event of major disaster
*alternate care sites (health care and other, ex: schools)

The Special case of bioterrorism: How to recognize it early
-Educate professionals to recognize candidate diseases
-Monitor ERs for patterns of symptoms (also develop algorithms to identify trends on internet)
-develop labs capable of identifying relevant viruses/bacteria
-improve communications among local, state, and national health agencies, and with non-governmental organizations (hospitals and voluntaries)

Legal authorities
-After 9/11 CDC developed Model State Emergency Health Powers Act to give health departments (and police, etc.) powers needed in emergencies (ex: right to quarantine)
-Most states adopted some measures in model legislation

CDC Coordinating Office for Terrorism Preparedness and Emergency Response
-Funding guidance and technical assistance to states
-Maintenance of Strategic National Stockpile
-Emergency Operations Center
-Training of emergency personnel

National Incident Management System (NIMS)- From Homeland Security, 2004
-Standardized, on-scene, all-hazard incident management concept
-Allows users to adapt organizational structure to match complexities and demands of single or multiple incidents without being hindered by jurisdictional boundaries

Why should states and localities use NIMS?
-incident commanders overloaded
-lack of accountability
-communications weak
-interagency cooperation not well integrated
-adoption required for federal preparedness assistance

Planning at different levels
Planning occurs at many levels: in educational institutions, community health orgs, etc

Challenge of coordination: Number of agencies involved in 9/11 response
>19 city, state, and federal agencies
-hospitals
-NGOs

Risk communication and preparedness
-in 2009, 75 percent of Homeland Security professionals believed US would experience another 9/11 like attack within next five years
-57 percent considered America safer than in 2001
-94 percent believed Americans not knowledgeable about appropriate steps in event of terrorist attack in their home town

Risk communication and preparedness (more)
-In 2007, eighty percent of Americans were concerned about another major terrorist attack
-47 percent believed they would personally experience a terrorist attack or weather disaster in the next five years
-yet only 34 percent had prepared personally for a major disaster; 43 percent had family emergency plan

Dilemmas in risk communication
-Too much vs. too little information, and how delivered
*candor vs. secrecy
*speculation vs. refusing to speculate
*being alarming vs. being reassuring : evidence re responses to fear
-tentativeness vs. confidence

Dilemmas in risk communication, continued
-Planning for denial vs. planning for panic
-How to communicate once you have decided WHAT to communicate
-“boy who cried wolf” phenomenon-starts being meaningless

Conclusion
Successful emergency preparedness requires:
-partnership between public health, public safety, law enforcement, and medical system- private & public
-rational planning, with full resourcing at all levels
-effective communication of risks
-planning to prevent emergencies and to respond appropriately to both immediately and in longer term to minimize damage and maximize extent and speed of recovery

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